A CLINICAL STUDY ON POST OPERATIVE COMPLICATIONS

AFTER MODIFIED RADICAL MASTECTOMY IN GGH

ANATHAPUR
1. DR. K. V. MADHUSUDHAN, MS, ASSISTANT PROFESSOR OF SURGERY, GGH,
ANANTHAPUR, AP, INDIA MADHUJWALA@GMAIL.COM, 9493344388
2. DR. B. UJJANESWARI, MS, ASSISTANT PROFESSOR OF SURGERY, GGH, ANANTHAPUR,
AP, INDIA, DRUJJINESWARI@GMAIL.COM, 7032937603
3. DR. VURITI MRUDULA KUMARI, MS, MCH PEDIATRIC SURGERY ASSISTANT
PROFESSOR OF SURGERY, GGH, ANANTHAPUR, AP, INDIA,
MRUDULAVURITI@GMAIL.COM , 8903181659
CORRESPONDING AUTHOR: DR. VURITI MRUDULA KUMARI, MS, MCH PEDIATRIC SURGERY
ASSISTANT PROFESSOR OF SURGERY, GGH, ANANTHAPUR, AP, INDIA
ABSTRACT
Introduction: Breast carcinoma management is multidisciplinary with surgery, radiotherapy, and
hormonal therapy, and chemotherapy.1 However, surgical management is the hallmark of the
treatment of breast carcinoma. "Modified radical mastectomy" is the most commonly employed
surgery.2 Complications contribute to morbidity, prolong the hospital stay, cost, and interfere with the
management of breast cancer. E- operative evaluation, meticulous techniques, hemostasis, and wound
closure can decrease complications. Aims & Objectives: To study the postoperative complications of
Modified radical mastectomy, To identify the triggering factors of and to know the preventive and
treatment modalities for complications. Patients and Methods: Prospective observational study on 100
Patients diagnosed with breast carcinoma that undergo Modified radical mastectomy in the Department
of General Surgery at a GGH Anathapur over a period of one year. Conclusion: Seroma formation (18%),
surgical site infection were common complications. The patient's age, obesity, diabetes, electrocautery
dissection, and early removal of drain were found as risk factors for seroma formation.
Key Words: Carcinoma Breast, Mastectomy, Seroma, Electro Cautery

INTRODUCTION

Over 2.3 million females were diagnosed with breast carcinoma and 685 000 deaths globally in 2020.
3
Woman dies from breast cancer, mainly because of wide spread metastasis. The modern approach to
breast carcinoma management is multidisciplinary; including surgery, radiotherapy, and hormonal
therapy, and chemotherapy.1 However, surgical management is the hallmark of the treatment of breast
carcinoma. "Modified radical mastectomy" is the most commonly employed surgery for breast
carcinoma.2

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 Early surgery complications are defined here as complications occurring within 1 month
after surgery, include wound infection, seromas, altered sensation along the anterior axillary fold, wound
dehiscence, flap necrosis, and hematomas. Based on different surveys, surgical site complications after
4,5
breast surgeries are 0.8 to 26% wide- ranging incidence.

Seroma formation is the most frequent postoperative complication with an incidence of 3% to

6
85%. Infection developing within seroma increases morbidity and often results in the need for
7
readmission, reimaging, drainage, and antibiotic usage. Incidence rates of Postoperative wound
8
infections vary and range from 3% to 19%. The incidence of Flap necrosis is between 3% and 32%.
Incidence of functionally significant lymph edema is <10%. Thorough pre-operative evaluation,
meticulous techniques, hemostasis, and wound closure can decrease complications.
RESULTS
Table 1: Distribution of Cases By Age

Age No of Cases Percentage

41 – 50 30 30
51 – 60 46 46
61 – 70 24 24
Total 100 100
Mean ± SD 50.31 ± 7.91

In the present study 63% of the patients had BMI between the 18.6 – 24.9kg/m2 and 28% of the

patients had 25-29.9kg/m2 and 7% of the patients’ ≥ 30kg/m2, 2% of the patients less than 18.5 kg/m2.

The mean and standard deviation of the patient's BMI were 24.27kg/m2 and 3.56, respectively.
In the present study, 20% patients were Diabetic, 8% hypertension, and 6% had both
hypertension and diabetes. Mean and standard deviation of Hb value was 10.67gm/dl and 1.39,
respectively. 49% patients were found to be right- sided tumor. The mean tumor size and standard
deviations were 5.15cm and 2.17cm, respectively.
In this study, 41% of the patients were treated by neoadjuvant chemotherapy. The mean duration
of surgery and standard deviation were 124.85minutes and 19.29minutes, respectively. In this
study,50% of the usage of electrocautery during surgery and 50% of scissor usage to dissect the tissue
during surgery.
Table 2: Comparison Of Complications With Risk Factors On POD 4

No Seroma FN WD SSI AS Hematoma

<50 7 3 0 0 2 1 1
Age (Yrs)
>50 13 8 1 1 0 2 1

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 <25 8 1 1 1 1 3 1
BMI( Kg/m2) 25-30 8 6 0 0 1 0 1
>30 4 4 0 0 0 0 0
DM 5 3 0 1 0 0 1
HTN 3 3 0 0 0 0 0
DM+ HTN 4 3 1 0 0 0 0
Duration of <150 19 10 1 1 2 3 2
Surgery
>150 1 1 0 0 0 0 0
(Min)
Dissection EC 15 13 0 1 1 0 0
device SC 9 2 1 0 1 3 2
<500 1 1 0 0 0 0 0
Total drain
500 – 1000 18 10 1 1 2 2 2
output(ml)
>1000 1 0 0 0 0 1 0
Drain <10 3 1 0 0 0 2 0
removal 10-15 17 11 1 1 1 1 2
day(days) >15 4 3 0 0 1 0 0
lymph Nil 0 0 0 0 0 0 0
nodes <15 9 5 1 1 0 1 1
removed >15 15 10 0 0 2 2 1

Table 3: Comparison Of Complications With Risk Factors On POD - 10

No Sero ma FN WD SSI AS Hematoma
<50 8 4 2 0 2 0 0
Age(yrs)
>50 14 3 0 2 9 0 0
<25 6 3 0 0 3 0 0

BMI(kg/m2) 25 – 30 11 3 2 2 4 0 0
>30 5 1 0 0 4 0 0
DM 11 1 1 1 8 0 0
HTN 0 0 0 0 0 0 0
DM + HTN 3 0 1 1 1 0 0
Duration of <150 16 7 2 2 5 0 0
surgery
>150 6 0 0 0 6 0 0
(min)
Dissectio EC 9 2 2 1 4 0 0

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n device SC 9 1 0 1 7 0 0
<500 5 0 0 1 4 0 0
Total drain
500 – 1000 16 7 2 1 6 0 0
output(ml)
>1000 1 0 0 0 1 0 0
Drain <10 3 2 1 0 0 0 0
removal 10-15 9 1 0 2 6 0 0
day(days) >15 6 0 1 0 5 0 0
Lymph Nil 0 0 0 0 0 0 0
nodes <15 6 1 1 1 3 0 0
removed >15 12 2 1 1 8 0 0

Table 4: Comparison Of Complications With Risk Factors On POD - 28

No Sero ma FN WD SSI AS Hematoma
<50 2 0 0 1 0 1 0
Age(yrs)
>50 1 0 0 1 0 0 0
<25 1 0 0 0 0 1 0

BMI(kg/m2) 25 – 30 1 0 0 1 0 0 0
>30 1 0 0 1 0 0 0
DM 1 0 0 1 0 0 0
HTN 0 0 0 0 0 0 0
DM + HTN 0 0 0 0 0 0 0
Duration of <150 2 0 0 1 0 1 0
surgery
>150 1 0 0 1 0 0 0
(min)
Dissectio EC 1 - - 1 - - -
n device SC 2 - - 1 - 1 -
<500 1 0 0 1 0 0 0
Total drain
500 – 1000 1 0 0 0 0 1 0
output(ml)
>1000 1 0 0 1 0 0 0
Drain <10 1 0 0 1 0 0 0
removal 10-15 2 0 0 1 0 1 0
day(days) >15 0 0 0 0 0 0 0
Lymph Nil 0 0 0 0 0 0 0
nodes <15 3 0 0 1 0 0 0
removed >15 0 0 0 1 0 1 0

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DISCUSSION
Seroma Formation: In the present study, seroma was the most common complication found with an
9
incidence of 18%; this was in the range of other studies like Altinyollar H et al with 15.5% and Bhatty I

with 20%, and Dahri FJ et al11 with the 33.33%. On the contrary, Kuroi K et al
10 12
et al quoted that
existing evidence was inconclusive for seroma formation.
Hematoma:
13
In the present study, hematoma developed in 2 patients (2%). In Obadiel Y A et al studies, hematoma
14
was found in one case(2%). This is comparable with the Rajiv Sharma et al studies in which bleeding
was found more with scissor dissection and post-operative development of a hematoma.
Altered Sensation: In this study, altered sensation along the anterior axillary fold was found in 4
15
patients. Couceiro et al study explained why occurring in the younger group, as increased nerve
sensitivity and lower threshold due to anxiety and more aggressive nature of breast carcinoma
needs aggressive surgical treatment.
th
Surgical Site Infection (SSI): This study found SSI in 2 patients on the 4 postoperative day and 11
th
patients on the 10 postoperative day. Surgical site infection was found in 13 cases (13%). In the
16
study conducted by Chandrakar N et al SSI were found in 10 cases (24.39%). Obadiel Y A et
13
al studies were found in 14 patients (28%).
Flap Necrosis: In this study, ap necrosis was found in 3 cases (3%), one case on t h e 4 t h
th
postoperative day and 2 cases on the 10 postoperative day. Flap necrosis was observed with a
17
higher BMI in this study. Robertson SA et al study found higher BMI was the risk factor.

CONCLUSION
 Seroma (18%) was the most common early postoperative complication. It is due to multiple
risk factors like increased age, higher BMI and comorbidities, early drain removal and excessive
lymphatic dissection, and electrocautery dissection without ligation of lymphatic vessels.
 Surgical site infection (13%) is the next common complication, and risk factors are older age
group, diabetes, and prolonged drainage.
 Wound dehiscence (5%) occurs in older people with diabetes and seroma formation with
infection cases.
 Flap necrosis (3%) can be seen in higher BMI, diabetes and hypertension, electrocautery
dissection.

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  Hematoma and altered sensation along the anterior axillary fold complications are less than
other complications.

REFERENCES
1. Fujii T, Le Du F, Xiao L, Kogawa T, Barcenas CH, Alvarez RH, Valero V, Shen Y, Ueno NT.
Effectiveness of an Adjuvant Chemotherapy Regimen for Early- Stage Breast Cancer: A
Systematic Review and Network Meta-analysis. JAMA Oncol. 2015 Dec;1(9):1311-8.
2. Henke, G., Knauer, M., Ribi, K. et al. Tailored axillary surgery with or without axillary lymph node
dissection followed by radiotherapy in patients with clinically node-positive breast cancer
(TAXIS): study protocol for a multicenter, randomized phase-III trial. Trials 19, 667 (2018).
3. https://www.who.int/news-room/fact-sheets/detail/breast-cancer
4. Prospero E, Cavicchi A, Bacelli S, Barbadoro P, Tantucci L, D'errico MM. Surveillance for
surgical site infection after hospital discharge: a surgical procedure-speci c perspective. Infect
Control Hospital Epidemiol. 2006 Dec;27(12):1313-7.
5. Ruvalcaba-Limón E, Robles-Vidal C, PoitevinChacón A, Chávez-MacGregor M, GamboaVignolle
C, et al. Complications after breast cancer surgery in patients treated with concomitant
preoperative chemoradiation: a case–controanalysis. Breast Cancer Res Treatment. 2006 Jan
1;95(2):147-52.
6. Agrawal A, Ayantunde AA, Cheung KL. Concepts of seroma formation and prevention in breast
cancer surgery. ANZ J Surg. 2006 Dec;76(12):1088-95.
7. Stanczyk, M., Grala, B., Zwierowicz, T. et al. Surgical resection for persistent seroma, following
modi ed radical mastectomy. World J Surg Onc 5, 104 (2007).
8. Vitug A, Newman L. Complications in breast surgery. Surg Clin North Am. 2007 Apr;87(2):431-
51.
9. Altinyollar H, Kapucuoglu N, Pak I, Berberoglu U. Lymphatic mapping and sentinel
lymphadenectomy in early stage breast carcinoma. J Experiment Clin Cancer Res.
2000;19(2):141-4.
10. Bhatty I, Ibrahim M, Chaudhry ML. Complications after modi ed radical mastectomy in early
breast cancer. Pak J Medi Sci. 2004;20(2):125-30.
11. Dahri FJ, Awan MS, Qazi AR, Khaskheli NM, Soomro IA. Early wound complications following
modi ed radical mastectomy with axillary clearance. J Surg Pak (Int). 2011 Oct;16(4) .
12. Kuroi K, et al. Evidence-Based Risk Factors for Seroma Formation in Breast Surgery. Jpn J Clin
Oncol. 2006. 36 (4) 1 97–206.
13. Obadiel, Y.A., Al-Ba'adani, M.N. and Haidar, Q.H. (2020) Early Complications ollowing Modi ed
Radical Mastectomy—Among Breast Cancer Patients Admitted to AL Gomhory Teaching Hospital,
Sana'a, Yemen between Jan. 2019-Jan. 2020. Open Access Library Journal, 7, 1-1.

2181
14. Sharma R, Rajan N Singh, Singh R. Comparative Study of Complications Following Electrocautery
Dissection vs Conventional Scalpel/Scissor Dissection in Modi ed Radical Mastectomy. Curr
Trends Diagn Treat 2018;2(2):98-101.
15. Couceiro TC, Valenca MM, Raposo MC, et al. Prevalence of post-mastectomy pain syndrome and
associated risk factors: a cross-sectional cohort study. Pain Manag Nurs 2014;15:731-7.
16. Chandrakar N, Shinde RK. Study the early complications of modi ed radical mastectomy performed.
Int Surg J 2019;6:239-43.
17. Robertson SA, Jeevaratnam JA, Agrawal A, Cutress RI. Mastectomy skin ap necrosis: challenges
and solutions. Breast Cancer (Dove Med Press). 2017;9:141-152. Published 2017 Mar 13.

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